What is pain management?

Pain from treatment or the cancer itself can affect your quality of life. So, controlling pain is a crucial part of your care.

The goal of pain management is to have the most pain control with the least amount of medication (to limit side effects). This allows you to get the most benefit from the treatments aimed at reducing your cancer.

Let your health care provider(s) know about any pain or discomfort you have.

Pain

Pain is not the same for everyone. Even among people at the same stage of disease, pain can vary. Some people have more intense and more frequent pain than others.

You should never feel you have to endure pain. Even when pain is mild, it can interfere with daily life and make other side effects, such as fatigue, seem worse.

Tell your health care provider as soon as you have pain

Let your health care provider(s) know about any pain or discomfort you have.

Pain is usually easier to treat when you first have it. Waiting until the pain is severe before getting relief can make it harder to control and may require more medication. So, it’s important to talk with your provider as soon as you have any pain.

Health care providers and palliative care or pain specialists

Every visit with your health care provider should include a discussion of pain.

Your provider can change the type and dose of pain medication throughout your care in response to your needs.

Your provider may suggest different types of pain control as your needs change. This ensures you are getting the most benefit from available therapies and are as comfortable as possible.

What is palliative care?

Palliative care focuses on relieving or preventing symptoms (like pain) rather than treating disease and should be given throughout treatment for breast cancer. Palliative care is especially important for those living with metastatic breast cancer.

Palliative care is an extra layer of care that can be given along with treatments for the breast cancer to maximize quality of life.

Palliative care specialists focus on symptom control, rather than control of the cancer. They treat physical, emotional, social and spiritual needs [63].

Palliative care is a standard part of metastatic breast cancer care and becomes the focus of care when active treatment ends. It can improve quality of life for patients and caregivers [64-65].

Palliative care and pain specialists

Palliative care and pain specialists (physicians, nurse practitioners and nurses) treat pain from cancer or other causes. They treat people with metastatic breast cancer as well as those with early breast cancer.

Palliative care specialists work with oncologists to give extra care to help people maintain the best quality of life possible. They have special training in treating pain and other symptoms, such as fatigue, anxiety and depression.

They can help people weigh the burdens and benefits of different treatments for symptoms as well as for medications or other therapies to treat the cancer.

Palliative care specialists can also help with advance care planning. They can help people identify their personal values and goals that will guide their care.

Anesthesia pain experts are anesthesiologists with special training in pain management. They are experts in procedures (such as injections) to relieve pain.

Seeing a palliative care or anesthesia pain specialist

You may have a palliative care or anesthesia pain specialist on your treatment team. If not, your oncologist will likely know of a specialist in your area.

Be sure to ask your oncologist for a referral if:

Your pain is not controlled

You have side effects from the pain medications

You are worried about becoming addicted to the pain medications

You would like to discuss more options to manage your pain

You may only need to see the specialist once. Your provider should be able to follow the specialist’s recommendations and carry out your pain management plan. If the treatment is effective, you shouldn’t need to see the specialist again.

For a list of pain management centers and palliative care programs in your area, call the National Cancer Institute toll-free at 1-800-4-CANCER (1-800-422-6237) or the American Cancer Society toll-free at 1-800-ACS-2345 (1-800-227-2345).

Reduce the need for radiation therapy and surgery related to bone fractures and bone pain

How are bisphosphonates given?

Bisphosphonates are given once a month or every 3 months by vein (through an IV).

How is denosumab given?

Denosumab is given once a month as an injection (not an IV).

Side effects

In some people, bisphosphonates and denosumab can cause bone, joint or muscle pain [38-39]. Any of these side effects should be reported to a health care provider right away.

Some people who take bisphosphonates need to increase their intake of vitamin D and calcium. If you develop muscle twitching or increased anxiety, ask your provider if you should take supplements to keep your vitamin D and calcium levels up.

In rare cases, with either type of drug, a disorder called osteonecrosis of the jaw may occur [38-39]. Before you start treatment with bisphosphonates, it’s a good idea to have a dental exam [39].

Talk with your oncologist before getting any dental procedure while you are being treated with bisphosphonates or denosumab.

Radiation therapy and surgery

Radiation therapy and surgery can be used to ease the pain of bone metastases.

Radiation therapy

Radiation therapy to the bone can relieve pain at the site of the tumor(s) and prevent fractures.

Drugs called radiopharmaceuticals (samarium (Quadramet) or alpharadin (Xofigo)) can also treat pain from bone metastases. If you are likely to benefit from this therapy, your oncologist can refer you to a doctor who specializes in nuclear medicine.

Surgery

Surgery is used to prevent or repair bone fractures.

Pain related to lymphedema

Pain from lymphedema can be relieved through treatment of the lymphedema itself.

Non-opioid and opioid pain medications

Non-opioid drugs

When pain is mild to moderate, the first choice for pain relief is usually a non-opioid drug.

Examples of these drugs include ibuprofen (such as Advil or Motrin), naproxen (Aleve or Naprosyn) and acetaminophen (Tylenol). Although you can get these medications without a prescription, check with your health care provider before taking them. There may be medical reasons you shouldn't take these drugs.

If pain persists or becomes worse, opioid drugs in combination with or instead of non-opioid drugs give added pain relief.

In general, the more pain medication you take, the more side effects you will have.

Health care providers try to treat pain with the least amount of medication to limit side effects.

Opioid drugs

Opioid drugs include (in order of the most commonly used):

Morphine

Oxycodone

Hydromorphone

Fentanyl

Methadone

Oxymorphone

Buprenorphine

Opioids are only available by prescription.

Opioids tend to have more side effects than non-opioid drugs, so they are only given after non-opioid drugs can no longer control pain.

While being treated with opioids, avoid alcohol, sleep aids and other medications that cause drowsiness because they can have a harmful interaction.

Some opioid medications contain both opioid and non-opioid drugs.

For example, Percocet contains oxycodone (an opioid) and acetaminophen. To ensure you don't take too much of the non-opioid drug, talk with your health care provider before taking any over-the-counter medications, especially those containing acetaminophen or non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen.

Morphine, oxycodone, hydromorphone and oxymorphone are available as oral sustained release medications that control pain for 8-12 hours

Methadone takes about 3-5 days to get the full pain relieving effect, but then has sustained high levels of pain relief if taken 2-3 times a day

Fentanyl and buprenorphine are available in a patch form that delivers medication through the skin. Fentanyl patches are changed every 48-72 hours. Buprenorphine patches are changed every 7 days.

Constipation, drowsiness, nausea, slowed breathing and itchiness

All but constipation may go away after a few days, but some of the side effects will need treatment

Methadone can be very dangerous if not taken exactly as prescribed

Potential barriers to pain management with opioids

People may worry about taking opioid medications, fearing side effects or addiction.

However, when used as prescribed, these drugs can offer a great deal of pain relief and will not cause addiction.

Side effects

Regular use of opioids almost always causes side effects, especially constipation. Your health care provider can help you prevent or control side effects so you can continue taking your medication.

If you become overly sleepy, you or your family should contact your provider right away.

Nausea and vomiting can occur after starting opioids, but these side effects tend to go away after a few days.

If you have itching or a rash, it may be a sign of an allergic reaction to opioids. Tell your provider and he or she can change your medication.

If pain increases over time, a higher dose of opioid medication may be needed.

Most people build up a tolerance to the side effects of these drugs, so they can handle the side effects of increased doses more easily [66].

Fear of addiction

Health care providers are careful to monitor the amount of opioids they prescribe so you don't take too much. Many providers will fill out a written opioid agreement with you if you are taking opioid medications regularly.

If you abruptly stop taking an opioid medication or the dosage is suddenly reduced, you may go through withdrawal symptoms (such as pain, anxiety, nausea and diarrhea).

A gradual reduction in the dose reduces the chance withdrawal symptoms will occur.

Withdrawal symptoms are a sign of physical dependence and are not related to addiction.

Physical dependence is a natural effect of regular opioid use, while addiction involves a loss of control over personal decisions about using a drug and can be related to harmful behavior.

It’s very rare for addiction to develop among people taking opioids for cancer pain, especially for those who haven’t had a problem with addiction in the past [66].

Other pain medications

Many drugs work with pain medications to reduce pain related to metastatic breast cancer. They include antidepressants, anticonvulsants, steroids and local anesthetics.

These drugs are only available by prescription. Before taking any of these medications, it's important to discuss their potential side effects with your health care provider.

The benefits of these medications are described in Figure 5.14.

Figure 5.14. Other medications used to treat pain

Examples

Pain relief benefit

Potential side effects

Antidepressants

Amitriptyline(Elavil)

Nortriptyline(Pamelor)

Duloxetine(Cymbalta)

Venlafaxine(Effexor)

Can relieve some neuropathic pain

Dry mouth, nausea, constipation and diarrhea

Less often, sleepiness, dizziness or fainting when standing and increased sweating

How pain medications are given

There are many ways to take opioid and non-opioid pain medications. Most are pills taken by mouth.

For people who have trouble swallowing pills, some medications are available in liquid form or a special tablet or strip that dissolves inside the cheek. A few pain relievers can be taken in the form of rectal suppositories.

Fentanyl and buprenorphine come in a patch form. This patch is placed on the skin and releases pain medication continuously over several days.

In cases of severe pain, when oral medications don't relieve the pain or when a person can't take medications by mouth, many drugs can be given by injection or by vein (through an IV).

Port-a-cath or a peripherally inserted central catheter (PICC)

Medications can be given into the vein through a port-a-cath or a peripherally inserted central catheter (PICC).

These have a portable pump that delivers the medication.

Some people get the medication continuously. Others can push a button to release an extra dose of medication for added relief (called patient-controlled analgesia).

Still others have both continuous mediation and the option to give themselves extra doses.

Implanted catheter

In rare cases, pain can't be controlled by the medications described above or their side effects are too severe.

In these cases, an implanted catheter can deliver the medications using a small, computerized pump to the space directly outside the spinal cord (epidural pump) or to the fluid around the spinal cord itself (intrathecal pump).

The pump is carried in a backpack or "fanny pack" (for epidural pumps) or implanted under the skin (for intrathecal pumps).

The pumps allow both continuous medication and patient-controlled extra doses for pain flares.

The pumps are programmed to prevent an overdose.

Complementary and integrative therapies (non-drug therapies) for pain

There are many non-drug therapies you may choose to use along with pain medications.

Care after treatment for the breast cancer ends

This can happen when treatment stops showing any benefit or when it greatly affects quality of life.

Once treatment for the cancer is stopped, reducing any cancer-related symptoms (called palliative care) becomes the main focus, rather than just a part of treatment.

Palliative care is given by your oncology team and palliative care specialists.

Your palliative care specialists can also help with your advance care planning.

Hospice

When life expectancy is 6 months or less, your health care provider may suggest you enroll in a hospice home care program.

Members of the hospice team give comprehensive palliative care to you and your family.

With your personal guidance, hospice can make the later stage of cancer care as comfortable as possible for you and your family.

The hospice care team works with your providers to give you the best care possible. Your oncologist or primary care doctor continues to guide your care and you can continue to see him or her.

This can be a very difficult time for you and your family. Your provider or hospital can arrange for counseling or a support group to help you address and manage the feelings and emotions that come with this stage of cancer care.

Our Breast Care Helpline 1-877 GO KOMEN (1-877-465-6636) provides free, professional support services to anyone with breast cancer questions or concerns, including people with metastatic breast cancer and their families. Calls are answered by a trained and caring staff member Monday through Friday from 9:00 a.m. to 10:00 p.m. ET and from 6:00 a.m. to 7:00 p.m. PT. You can also email the helpline at helpline@komen.org.